Evolving View of Vaginal Exams

As I told you, I have been taking advantage of the week before classes begin to update some information on the website. Some pages are really easy, others are mentally and emotionally taxing. Why? Because my knowledge base has changed since the pages were written, but my basic beliefs about birth have not. At the same time, my understanding of how a midwife makes decisions has changed, but the audience for the website has not. I am finding it a struggle to find a way to accurately represent the full scope of midwifery care to an audience who does not have the background knowledge I have an may be anywhere in the world. I know I will figure it out, it is just tough today.

For example, I am working on the page about judging progress in labor. There has been a progression, or evolution in my thinking about how to judge progress. I’d like to map out the major stops on the path for you.

Training as a childbirth educator: the training program stresses that cervical dilation is not an accurate gauge because sometimes women dilate very fast at the end. I accept that the only true way to judge progress is to watch the emotional map of labor to determine progress.

Working as a doula: see many examples of the emotional map working, and witness my first labor with unproductive but strong and progressive contractions, start to wonder how to know when the emotional map is wrong.

Begin international work: learn the importance of identifying women who need medical assistance in labor and learn about the use of the partogram

Begin studying as a midwife: learn the averages for labor based on studies and why the alert and action lines on various labor progress standards are drawn at specific places

Clinical rotation focusing on induction and epidural use: learn how these interventions change labor so I cannot recognize any of the normal cues I would see in a mother to determine how labor is progressing; accept that vaginal exams every two hours are probably a good thing when epidural is used

Provide labor assistance in Honduras: see how using the partogram with strong definition of active labor actually can reduce the number of vaginal exams with most women only having two – one on admission and one to confirm/ ensure pushing is effective.

That brings me to today, where I am looking at the words I wrote way back at step 2 and wondering how to put everything I have learned in one webpage.

Do I like vaginal exams – no. They are uncomfortable for the woman, and I think they tend to get over-used.

Would I recommend a woman utilize vaginal exams – almost always yes. I am willing to accept that when used properly they can provide me with valuable information to help a woman make good decisions before and during labor.

Now I just need to figure out how to explain that in a way that educates my readers enough to have the necessary discussions with whomever they pick to attend them in labor. I guess I just feel like saying “sometimes” this is important; or good; or useful; or necessary comes off like a cop-out to readers who haven’t spent the last twelve years studying birth.

More than that, I feel like saying vaginal exams are useful puts me on the “wrong” side of the natural birth fence. No matter how much I learn, my original training stays in my head as the “ideal” of what a natural birth can and should be. Anytime I deviate from their rigid standards I feel like I am being a traitor.

It is not just to that organization, but also the many of the homebirth midwives I work with. I have heard many of the same rigid standards of how labor should be manged from friends, and I have heard these friends belittle other midwives for the way they practice. Now I’ve become one of the midwives they belittle, and I’m not sure I can commit to that on my website.

But the truth is, if I trust my education and the hours of research and years of learning that have gone into my understanding of vaginal exams, I shouldn’t hesitate to share what I know. I’m just not sure I’m ready to have my friends think of me as one of “those” midwives. This isn’t easy.